Medicare Part D requires that every beneficiary can choose between at least two plans. Every initial drug plan must be approved by the government. The providers of the Prescription Drug Plans have to tell you what’s on the plan, how much it will cost, and how you will be able to access it. The Prescription Drug Plans have to give you 60 days’ notice before they remove a drug you are using from their plan. They must also notify you if they change the way that you pay for coverage. If you are on Medi-Cal and Medi-Cal covers a drug not listed on any Medicare Prescription Drug formulary, Medi-Cal will help pay for it.
If you need a drug that is not listed on your drug plan, you can file an appeal or an exception. You (the beneficiary) have to be the one who files the appeal to your drug plan. If the Prescription Drug Plan decides not to cover the drug, you can appeal their decision to an Independent Review Entity. If they deny your appeal, you can appeal that decision to an Administrative Law Judge. If the Judge denies your appeal, you appeal that decision to the Medicare Appeals Council. If they deny your appeal, you can appeal that decision to Federal Court. You can also have an expedited (faster) review.
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